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Dental diseases affect a large number of people, cause much discomfort and pain, and are costly to treat. Their impact is therefore considerable, to both the individual and wider society (see Chapters 3 and 21 for a more detailed overview of oral health impacts). A particular concern is the pervasive nature of oral health inequalities with the burden of oral diseases now increasingly experienced amongst less educated and socially excluded groups in society. The causes of dental diseases are well known and effective preventive measures have been identified. However, treatment services still dominate oral health systems around the world. There is growing recognition within the dental profession that treatment services will never successfully treat away the causes of dental diseases (Blinkhorn 1998). In the Lancet , one of the top medical journals, an editorial on oral health highlighted the need to reorient dental services towards prevention (Lancet 2009). What type of preventive approach should be adopted to promote oral health and reduce inequalities? It is essential that preventive interventions address the underlying determinants of oral disease and inequalities to achieve sustainable improvements in population oral health. Effectiveness reviews of clinical preventive measures and health education programmes have highlighted that these approaches do not reduce oral health inequalities and only achieve short-term positive outcomes. A radically different preventive approach is therefore needed. If treatment services and traditional clinical preventive approaches are not capable of dealing effectively with dental diseases, then other options need to be considered. In recent decades, the health promotion movement has arisen, partly in response to the recognized limitations of treatment services to improve the health of the public. With escalating costs and wider acceptance that doctors and dentists are not able to cure most chronic conditions, increasing interest has focused on alternative means of dealing with health problems. The origins of health promotion date back to the work of public health pioneers in the 19th century. At that time, rapid industrialization led to the creation of poor and overcrowded working and living conditions for the majority of the working classes in the large industrial towns and cities of Europe and North America.

For health services to deliver effective prevention and treatment, a detailed understanding of the factors influencing health is critical. These factors are known as the determinants of health. Failure to address the underlying causes of disease in society will mean that sustainable improvements in the health of the population and a reduction in health inequalities will never be achieved. Tackling the contemporary determinants of health across society is a core function of public health and has now become the focus of government health policy in many parts of the world (WHO 2008). Many clinicians often feel frustrated when their advice to patients on ways of staying healthy is apparently ignored. Why don’t people stop smoking when they know the serious health risks of the habit? Why do some parents continue to give their children sweets when they have been given clear advice on the harmful effects on the child’s oral health? It is important for all health professionals to understand the factors influencing their patients’ choices and actions. Clinicians equipped with this knowledge are more likely to be effective at supporting their patients and enjoying their professional work. When asked what factors determine health, many people would probably highlight the importance of modern medicine. The use of antibiotics, high-tech equipment, and surgical advances might all be given as the most important reasons for improvements in health that have been achieved in the last hundred years. Why is modern medicine credited with such achievements and is this a true reflection of reality? Professor Thomas McKeown, a pioneer in public health research, conducted a detailed historical analysis of the reasons for the steady reduction in mortality rates that occurred in westernized countries during the last century (McKeown 1979). In his classic analysis he investigated changes in mortality rates for different conditions. As can be seen in Figure 2.1, with infectious diseases such as tuberculosis, whooping cough, and measles, significant reductions in mortality rates occurred long before treatments and vaccination programmes were even introduced.